Mary Assunta is chair of the Framework Convention Alliance, an international network advocating for adoption and implementation of a strong Framework Convention on Tobacco Control, the global anti-tobacco treaty. She is a recipient of the 2003 Luther Terry Award for outstanding individual leadership in tobacco control, awarded by the American Cancer Society. A native of Malaysia, Assunta is currently conducting research into internal documents of the tobacco industry for her PhD in Public Health at the University of Sydney.

Mary Assunta: In the developed world, about 22 percent of women smoke, whereas in the developing world, it is a much smaller percentage, approximately 9 percent.

If we look at the Asian region, male smoking is still quite high, approximately 62 percent, whereas female smoking is only about 6 percent. More women smoke in countries like the Philippines and Japan — the smoking rate is 18 percent among women in the Philippines and 13.4 percent in Japan. In Southeast Asian countries, like Cambodia, Vietnam, Indonesia, the rates are much lower — less than 5 percent of the women actually are smoking in these countries.

There are several explanations for the differences between male and female smoking rates. Culture has definitely played a big role in keeping the figures small among women — this has to do with traditional values that are still being upheld. Low income is another factor — the bulk of the female population in many parts of Asia and in the developing world do not have disposable income and hence it is not that easy to buy cigarettes.

MM: How do those kind of gender-based smoking rate differentials get manifested in access to and spending of family resources?

Assunta: The situation varies considerably, but to take a very rough estimate: if it is a one-income household and if only the husband is working and if he is a pack-a-day smoker, then in a low-income family — and in Asia smokers are disproportionately from lower-income groups — that might take away approximately 10 percent of their income. This is just a very rough estimate, but it is quite significant for poor families.

MM: What are the trends in women’s smoking rates?

Assunta: Certainly more teenage girls are smoking.

To give an example: in Malaysia, the national average for adult women is 3.5 percent whereas for teenage girls it is about 8 percent. In Japan, the overall smoking rate is 13.4 percent for females, but if you look at younger smokers aged 20-29 years (in Japan, the minimum smoking age is 20), about 23.2 percent of women smoke.

I think that this trend is reflective of many Asian countries becoming more affluent. More teenage girls have more pocket money. Of course, there are other reasons as to why more of them are starting to smoke, including especially the role of the multinationals in marketing to them.

MM: How are the multinationals appealing to women smokers?

Assunta: Particularly over the last decade, you find that there have been numerous examples of tobacco multinationals, such as Philip Morris and British America Tobacco, directly promoting to women. They have done this by sponsoring pop concerts and disco parties, for example.

Secondly, the multinationals have made contributions to causes for women very much a part of their public relations and philanthropic activities in recent times. They have supported domestic violence and workplace ethics programs, and have even given scholarships to girls.

They have also engaged women as employees, to promote cigarettes. They have employed “Marlboro girls” in Vietnam and Cambodia. In recent times, they have sponsored Formula One races, where women may not be the ones racing, but they are definitely there playing a decorative role around the vehicle, around the races, on the podium. Girls from Japan have come dressed in red and white — the color of the Marlboro brand — to promote Grand Tour Races in Malaysia.

So there has been the involvement of women both in the receiving end and being direct employees in the promotion of tobacco. This has put women in the forefront of promotion. I think the more you find women being associated with brand names and out there being associated in a positive manner with the entire industry, that elevates smoking among women, and among young women particularly.

MM: How do the promotional activities of the multinationals compare with the national companies?

Assunta: The national companies that are monopolies are not as aggressive in promotional activities compared to multinationals. The kind of marketing tools that the multinationals bring are so powerful and glitzy, whereas the national monopolies have not really been so aggressive.

The classic example is when Japan was forced to undergo tobacco market liberalization. The Japanese monopoly had not engaged in very aggressive advertising and promotional activities, but once the market was open completely in 1987, then the advertising dollars just skyrocketed and you find these huge multimillion dollar budgets — the multinationals were able to bring tobacco marketing right into the homes, through television, to the masses.

MM: Do you see any difference among the multinationals, or are they basically all the same?

Assunta: I think they are basically the same. The top three now are Philip Morris, British American Tobacco and Japan Tobacco International. In 1999, when Japan Tobacco took over R.J. Reynolds International, I wanted to see if they would change their style or if it would remain the same. One of the things that R.J. Reynolds used to do in Malaysia is to sponsor rock concerts and pop concerts, particularly targeting young women, and especially for Salem. After Japan Tobacco purchased R.J. Reynolds International, this did not change. Rather than cutting back or changing RJR’s style, Japan Tobacco actually transformed into an aggressive transnational corporation.

MM: Given the current environment and the dominance of the global market by the three companies, what are the best policy interventions to reduce women’s smoking rates, or to prevent an upsurge?

Assunta: Every country must have a general national policy in place for tobacco control and they need to put in place the three basic evidence-based measures that work: first, a comprehensive ban on all tobacco advertising, promotions and marketing; second, a ban on smoking in all public places and workplaces; and third, a high level of taxation which is above 65 percent.

Once countries have got this in place, then I think you need to supplement this by having more specific, including gender specific, activities.

One is that governments need to involve women’s groups in the intervention. This is not happening in many countries. I get the feeling that because women’s organizations have been busy looking at basic needs issues, and fighting the larger issues, that tobacco has somehow been lost along the way, and that the bulk of them are not actively taking up tobacco control and putting it higher up the agenda. I think that tobacco needs to be integrated into the activities of women’s organizations and governments need to involve women’s organizations when drawing up tobacco control initiatives.

Then there are other specific activities that need to be put in place, including education and particularly gender-specific education. Even in medical school, this is something that has been just been ignored or not given enough emphasis.

But all of this will only make sense and bear fruit if the basic policies are in place.

MM: Are there examples of countries that have done a good job of women-focused tobacco control interventions?

Assunta: I think both Australia and New Zealand have been exemplary with regards to tobacco control initiatives that have produced results.

For Australia for this year, smoking prevalence is about 17.4 percent, which is really very good — one of the lowest in the world. It is down from 19.5 percent in 2001. If you look at the 2001 figures for women in Australia, about 18.6 percent of women smoked, whereas 21.1 percent of men smoked. Now it is down to 16.3 percent and 18.6 percent respectively.

For New Zealand, the prevalence for teenage girls is about 21 percent, down from about 25 percent in 2003. For teenage boys, it was about 13.8 percent for this year, down from 16.4 percent in 2003. So actually in New Zealand you have a case where more girls than boys are smoking, but both prevalences are coming down.

Singapore is the other country that has done very well for tobacco control, where prevalence for women in 1970 was about 4.5 percent, and it is now down to approximately 2.5 percent. But the prevalence for young girls is going up; the Singapore government is particularly concerned about this and addressing it.

In all three countries, governments have successfully implemented comprehensive tobacco control programs and specifically addressed gender so that they can fine tune the overall programs.

MM: To what extent will the Framework Convention on Tobacco Control (FCTC) help to reduce women’s smoking rates?

Assunta: In its preamble, the Framework Convention talks about the special contribution made by nongovernmental organizations (NGOs) including women’s groups, so it first of all acknowledges the contributions that women’s groups have made.

Secondly, Article Four establishes as a guiding principle the need to take measures to address gender-specific risks when developing tobacco control strategies. I think it is really useful, because then this empowers governments to start taking action.

If we look at the whole passive smoking issue, women and children are the most vulnerable. Governments need to pay attention to this and to involve women’s organizations in drawing up appropriate policies.

MM: What is the Framework Convention Alliance (FCA)?

Assunta: The FCA is a heterogeneous alliance of about 200 nongovernmental organizations from about 80 countries from around the world. The main objective of the alliance is to support the development, signing and ratification of an effective FCTC. Now that the FCTC has been adopted and entered into force in February of this year, the Framework Convention Alliance will be looking into the effective implementation of the FCTC, and also the development of related protocols.

The FCA is made up of national organizations and international coalitions, so it is really a very large alliance of a variety of groups. We’ve got so many different genres of members, which has brought a wealth of expertise to the NGO movement. I am certainly very excited about the things we will be doing in the future.

MM: What was the role of the FCA and other NGOs in getting the FCTC through?

Assunta: I would like to think that the FCA together with the other NGOs played quite a significant role during the FCTC negotiations.

One thing that we did do is to raise the bar on the issues that were being debated and discussed. The other thing that the FCA did was to keep the negotiation process transparent and honest.

With all negotiations, there is a lot of diplomatic posturing that goes on. What the NGOs did was to keep reminding governments of why they were there: to negotiate a public health treaty, to arrest a global epidemic. It is a global epidemic that takes away one life every eight seconds, and hence the NGOs needed to keep the urgency during the negotiation process.

One of the ways in which the NGOs did that was to have a Death Clock, so that all of the delegates could see how many deaths were clocked throughout the negotiations. We had hoped this would help keep up the urgency because with negotiations it is quite easy for the delegates to get lost in semantics and details.

Another important activity of the FCA was to prepare technical reports and hold briefings for delegates. Many of the issues that were being debated were complex issues — smuggling, product regulation, labeling, packaging, tar levels, nicotine levels. The FCA technical briefings tried to discuss these issues with the delegates, to focus on precise text needed for effective policy.

Of course, there was also lobbying that took place, where we tried to get governments to cut through the niceties and get the strictest language possible in the text rather than general language. There is a whole lot of difference between between “shall” and “may,” between “restrict” and “ban.” We tried to lobby governments to put in stringent terms and stringent language.

One of the effective things the FCA did was publish daily bulletins during the negotiations, where we awarded Dirty Ashtrays to governments that played the spoiler role and Orchids to governments that did the right thing during the negotiations. I think this was quite effective, because the first thing governments would do whenever they saw the bulletin was to quickly turn to the back page to see if they have been named and what kind of award they received.

MM: Going forward, what are some of the top priorities for tobacco NGOs?

Assunta: Implementation of the FCTC is of utmost priority at the moment. But when you talk about implementation, you really need to ensure that governments are able to interpret the FCTC to the maximum, and not to interpret it in a loose and weak manner.

For example, the clause on packaging and labeling says that the size of the health warning should be about 30 percent. But that is just the minimum. The FCTC also talks about graphic warnings being an option, so it’s not compulsory. This is where governments need to be brave, and not just do the minimum. For example, Japan has just changed its pack warnings as of this year, and has opted for the lowest possible interpretation of the clause, which is 30 percent and a text-only warning. Thailand and Singapore on the other hand have opted for 50 percent graphic warnings, which is excellent.

So our challenge is to ensure that governments choose the more stringent interpretation rather than the weak one.

Another challenge is that the number of smokers, globally, is going to go up, simply because of rising population. This means that we really need to step up our efforts. We really need to treat smoking seriously as a global epidemic and give tobacco control the proportionate action that it deserves.